Adverse effects of long-term proton pump inhibitor use: a review for the otolaryngologist.

OBJECTIVE: Proton pump inhibitors (PPIs) are the mainstay of current medical management for laryngopharyngeal reflux, and treatment often involves long-term use of this class of medications. The long-term adverse effects of PPI use have not been studied extensively, but several analyses have demonstrated epidemiological links between PPI use and adverse outcomes. These include altered mineral and vitamin absorption, orthopedic injury, acute coronary syndromes (ACS), and infectious risks. STUDY DESIGN: A PubMed search was performed for subject headings, including PPIs and adverse outcomes. Relevant studies were included in this review. Studies were compiled, reviewed, and compared in a narrative form. RESULTS: Several epidemiological links between PPI use and metabolic, infectious, cardiac, and orthopedic adverse outcomes were found. No definite causal effects were identified. CONCLUSION: Given these epidemiological patterns, we recommend that the clinician be aware of these possible unintended consequences. In addition, we recommend consideration of dual-energy X-ray absorptiometry (DEXA) bone density scans in at-risk patients who have not been previously tested. We recommend consideration of vitamin B12 and iron levels in selected patients who are at high risk. We also recommend close communication with our cardiology colleagues, as we attempt to ascertain the relationship between clopidogrel and PPI use. We recommend caution in the use of omeprazole in patients undergoing active treatment for ACS. Finally, we recommend consideration of Helicobacter pylori or serum gastrin level testing in patients with known risk factors for gastric carcinoma.

Fluoroscopic surrogate for pharyngeal strength: the pharyngeal constriction ratio (PCR).

The pharyngeal constriction ratio (PCR), derived directly from videofluoroscopy without the need for manometry, requires validation as a surrogate for pharyngeal strength. A correlation of -0.70 was previously identified between PCR and pharyngeal clearing pressures (PP) on separate fluoroscopic and manometric studies. As PP increases, PCR decreases. The objective of the current study was to evaluate the correlation between PCR and PP in 25 patients undergoing simultaneous fluoroscopy and pharyngeal manometry. The effect of the manometric catheter on PCR was also investigated. The correlation between the PCR and averaged pharyngeal clearing pressures was -0.72 (p<0.001). All patients with a PCR>0.25 had a P <60 mmHg. PCR did not differ significantly as a consequence of the manometric catheter. Results suggest the utility of an objective fluoroscopic measure in assessing pharyngeal strength when manometry may not be available or possible.

Clinical, histopathologic, and radiographic indicators of malignancy in head and neck paragangliomas.

OBJECTIVE: The goal of this study is to review our series of head and neck paragangliomas to identify factors that may help in predicting malignancy. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: Subjects with head and neck paragangliomas at our institution from 1976 to current were reviewed. In addition to statistical comparisons of epidemiologic factors, pathologic and radiographic characteristics were reviewed. RESULTS: Of the 84 subjects, there were seven malignant paragangliomas (8%). Age was found to be significantly different between the benign and malignant subgroups, with an average age of 54 ± 16 and 40 ± 12 years, respectively (P = 0.02). Pain was a presenting complaint in five patients with benign disease (6%), and five of the seven malignant patients (71%) presented with pain, showing a significant association between pain and disease type (P < 0.0001). The odds ratio for a patient with pain having a malignant tumor was 36 (95% CI: 5.5-234). Enlarging neck mass was noted in all cases of malignant disease, but only in 31 percent of cases of benign disease (P < 0.0001). In a secondary analysis of carotid body tumors alone, enlarging neck mass was not found to be significant between benign and malignant disease (P = 0.14). However, pain continued to be significantly different, with 67 percent of malignant lesions demonstrating pain, compared with only 11 percent of benign lesions (P = 0.01). CONCLUSION: This study suggests that pain, a rapidly enlarging neck mass, and younger age are predictive factors of underlying malignancy, which should prompt one to consider an aggressive diagnostic and management approach.

Esophageal pathology in patients after treatment for head and neck cancer.

OBJECTIVE: To determine the prevalence of esophageal pathology following treatment for primary head and neck cancer (HNCA). STUDY DESIGN: Case series with planned data collection. SETTING: Academic medical practice. SUBJECTS AND METHODS: Subjects comprised HNCA survivors. Esophagoscopy was prospectively performed on 100 patients at least three months after treatment for HNCA. Patient demographics including cancer stage, cancer treatment, use of reflux medications, symptoms surveys, and esophageal findings were prospectively determined. RESULTS: The mean age of the cohort was 64 (+/- 10) years; 75 percent were male. The mean time between the end of treatment and endoscopy was 40 (+/- 51) months. Eighty-one percent of HNCA was advanced stage (3 or 4). The distribution of site of the primary HNCA was as follows: oropharynx (38%), larynx (33%), oral cavity (17%), unknown primary (10%), hypopharynx (1%), and nasopharynx (1%). Treatment modalities included surgery alone (15%), surgery with radiation (34%), radiation alone (6%), chemoradiation alone (24%), and chemoradiation with surgery (20%). The findings on esophagoscopy included peptic esophagitis (63%), stricture (23%), candidiasis (9%), Barrett metaplasia (8%), gastritis (4%), and carcinoma (4%). Only 13 percent had a normal esophagoscopy. CONCLUSION: Esophageal pathology is extremely common in patients treated for HNCA. These findings support routine esophageal screening after HNCA treatment.

Transnasal balloon dilation of the esophagus.

OBJECTIVE: To describe the safety of transnasal balloon dilation of the esophagus. DESIGN: Retrospective case series. SETTING: Two tertiary care institutions. PATIENTS: All patients undergoing transnasal balloon dilation of the esophagus. MAIN OUTCOME MEASURE: Complications. RESULTS: Fifty-four transnasal esophageal balloon dilations were performed in 38 patients. The mean age of the cohort was 65 years (range, 13-88 years). Twenty-nine patients were male (76%). Twenty procedures were performed using only topical anesthesia in the office setting. Seven patients (18%) were postlaryngectomy, and 15 patients (39%) had a history of head and neck radiation therapy. The upper esophageal sphincter (UES) was the most frequent dilation site (63%), followed by proximal/mid esophagus (26%), lower esophageal sphincter (LES) (7.4%), and both the UES and LES (3.7%). Indications included cricopharyngeal dysfunction, benign stricture, web, and Schatzki ring. Two procedures (3.7%) were aborted secondary to self-limited laryngospasm or gagging. There were no clinically significant complications. CONCLUSIONS: Transnasal esophageal balloon dilation can be performed in unsedated or sedated patients with a very low complication rate. The procedure is well tolerated in 96% of patients. This technique, formerly available only through larger caliber oral gastroscopes and under sedation, allows for office-based esophageal balloon dilation in an otolaryngology practice.

Postviral vagal neuropathy.

OBJECTIVES: Postviral vagal neuropathy (PVVN) is a clinical diagnosis characterized by laryngeal complaints initiated by an upper respiratory tract infection (URI). Little is known about the natural history of this disease, and only small case series have been reported. We describe the clinical presentation, symptoms, patient demographics, and natural history of PVVN. METHODS: A cross-sectional survey of all patients with a diagnosis of PVVN from January 1, 2006, to December 31, 2006, was prospectively administered, detailing disease onset, type and duration of symptoms, demographics, and previous treatment. The Reflux Symptom Index, Voice Handicap Index, and laryngoscopic findings were collected for each patient. RESULTS: Forty-four patients with PVVN were identified. The mean age (+/-SD) was 48 +/- 13 years, and 73% of the patients were female. The most common initial URI symptoms were cough (89%), nasal congestion (75%), and rhinorrhea (64%). Fifty-nine percent of the patients took antibiotics, and the mean time between symptom onset and presentation to the laryngologist was 83 +/- 127 weeks. The most common persistent symptoms were cough (52%), throat clearing (48%), dysphonia (41.5%), and vocal fatigue (43%). Fifty-seven percent of the patients consulted 3 or more physicians for their symptoms. The mean Voice Handicap Index was 13.4 +/- 10.3, and the mean Reflux Symptom Index was 17.7 +/- 11. Forty-nine percent of the patients had evidence of vocal fold paresis on strobovideolaryngoscopy. CONCLUSIONS: PVVN is a clinical entity characterized by a complex of laryngeal symptoms that begin after a URI. The symptoms include chronic cough, excessive throat clearing, dysphonia, and vocal fatigue. Affected individuals are typically in their fifth decade of life and appear more likely to be women. Most patients have seen multiple physicians, and the time to laryngologist referral is often delayed.

Endoscopic removal of a giant fibrovascular polyp of the esophagus.

OBJECTIVES: Giant fibrovascular polyps of the esophagus are rare benign tumors originating from the proximal esophagus. These pedunculated lesions can grow to "giant" proportions. Asphyxiation from aspiration of the regurgitated polyp is a well-described cause of death. Traditional excision has involved a transcervical vertical esophagotomy. This report describes the successful endoscopic removal of a giant fibrovascular polyp of the esophagus. RESULTS: A 63-year-old man with dwarfism and obstructive sleep apnea was referred for evaluation of an esophageal mass that was intermittently regurgitated into the hypopharynx. Office esophagoscopy demonstrated a 10-cm giant fibrovascular polyp originating just below the cricoid cartilage. During endoscopic removal, the base of the lesion was exposed with a Weerda bivalved laryngoscope. Bipolar cautery combined with a snare was used to transect the base with excellent hemostasis. No esophageal leak was noted on an esophagogram on postoperative day 3. The patient then resumed a liquid diet and was discharged home, resuming a regular diet within a week. CONCLUSIONS: Giant fibrovascular polyps of the esophagus are life-threatening because of potential airway obstruction. This report describes the successful endoscopic removal of a giant fibrovascular polyp, avoiding the potential morbidity associated with a transcervical vertical esophagotomy.

Laryngopharyngeal reflux: the value of otolaryngology examination.

Laryngopharyngeal reflux (LPR) is the disease process by which gastric contents affect the extraesophageal structures of the head and neck. The symptoms of LPR include intermittent dysphonia, excessive throat clearing, globus pharyngeus, cough, and dysphagia. These symptoms can be assessed with the Reflux Symptom Index. Signs of LPR, as determined with laryngoscopy, can be described with the Reflux Findings Score, which includes assessment of site-specific laryngeal edema and other inflammatory changes. This article discusses the current understanding of LPR pathophysiology, taking into account pepsin stability and reactivation.

Thyrohyoid vocal fold augmentation with calcium hydroxyapatite.

OBJECTIVES: To review the clinical results of the thyrohyoid approach for in-office vocal fold augmentation with calcium hydroxyapatite. STUDY DESIGN: Retrospective chart review. METHODS: The charts of all persons who underwent in-office thyrohyoid vocal fold augmentation between June 1, 2005 and June 1, 2007 were reviewed. Information with respect to patient demographics, indications, complications, and clinical outcome was abstracted. RESULTS: Fifty-one thyrohyoid vocal fold augmentations were performed in 33 patients (26 men; mean age, 66 years). Six (13%) procedures were aborted as a result of an inability to achieve an appropriate injection angle. Two (6%) self-limited complications included a vasovagal episode and a small ulcer near the petiole of the epiglottis. Pre- and postprocedure data were available for 62.5%. The mean 10-item Voice Handicap Index improved from 27.9 (+/-8.40) preprocedure to 13.5 (+/-10.52) postprocedure (P < 0.001). CONCLUSION: In-office vocal fold augmentation with the use of the thyrohyoid approach demonstrates excellent clinical results. It has become our technique of choice for vocal fold medialization with the patient under local anesthesia in the office setting. Complications are rare.

Proximal suction tracheotomy tube reduces aspiration volume.

OBJECTIVE: Conventional cuffed tracheotomy tubes do not prevent aspiration of secretions. Aspiration of saliva may be decreased with the use of a subglottic suction port. STUDY DESIGN: Prospective. METHODS: Shiley Disposable Cuffed Tracheotomy (DCT) tubes sizes 4, 6, and 8 (Tyco Healthcare, Pleasanton, CA) were compared to Portex Blue Line Ultra Suctionaid (BLUS) tracheotomy tubes sizes 6, 7, and 8 (Fig 1; Smiths Medical, Watford, UK). All tubes were tested in a simulated tracheal model using 10 cc of human saliva with no suction, intermittent suction, and constant suction (15 minutes). RESULTS: There was a significant decrease in aspirate between the larger Shiley and BLUS tubes with intermittent suction (mean 8.38 mL Shiley 6 vs 1.60 mL BLUS 7; 8.50 mL Shiley 8 vs 2.80 mL BLUS 8). There was a significant decrease in aspirate between all sizes of Shiley and BLUS tubes with continuous suction. For BLUS 7 and 8, there was a significant difference between intermittent suction (mean, 1.60 mL, 2.80 mL, respectively) and continuous suction (mean, 0.20 mL, 0.60 mL respectively). Shiley and BLUS without suction were equivalent. CONCLUSION: Subglottic suction tracheotomy tubes reduce the risk of aspiration beyond the cuff in a bench-top model.

Esophagopharyngeal reflux.

OBJECTIVE: Laryngopharyngeal reflux (LPR) is the disorder caused by the regurgitation of gastric contents into the laryngopharynx. Many persons diagnosed with LPR who fail medical therapy regurgitate contents from the proximal esophagus into the laryngopharynx (esophagopharyngeal reflux or EPR) on cinefluoroscopy. STUDY DESIGN: Retrospective review. SUBJECTS AND METHODS: The charts of consecutive adult patients with findings of EPR on cinefluoroscopy were reviewed. RESULTS: Twenty patients met the diagnostic criteria for EPR (mean age, 50 years of age; 60% female). Most common symptoms were cough (40%), dysphagia (35%), dysphonia (25%), and chronic throat clearing (25%). Eighty-five percent had a prior diagnosis of acid reflux disease (LPR or GER) and were unsuccessfully treated with proton pump inhibitors and/or anti-reflux surgery; 15% had fluoroscopic oropharyngeal abnormalities; all patients had fluoroscopic esophageal abnormalities. CONCLUSION: EPR is characterized by regurgitation of proximal esophageal contents into the laryngopharynx. The symptoms are similar to LPR. EPR appears to be caused by a disorder of volume clearance and esophageal dysmotility not acid and peptic injury.

Validity and reliability of the Eating Assessment Tool (EAT-10).

OBJECTIVES: The Eating Assessment Tool is a self-administered, symptom-specific outcome instrument for dysphagia. The purpose of this study was to assess the validity and reliability of the 10-item Eating Assessment Tool (EAT-10). METHODS: The investigation consisted of 4 phases: 1) line-item generation, 2) line-item reduction and reliability, 3) normative data generation, and 4) validity analysis. All data were collected prospectively. Internal consistency was assessed with the Cronbach alpha. Test-retest reliability was evaluated with the Pearson product moment correlation coefficient. Normative data were obtained by administering the instrument to a community cohort of healthy volunteers. Validity was assessed by administering the instrument before and after dysphagia treatment and by evaluating survey differences between normal persons and those with known diagnoses. RESULTS: A total of 629 surveys were administered to 482 patients. The internal consistency (Cronbach alpha) of the final instrument was 0.960. The test-retest intra-item correlation coefficients ranged from 0.72 to 0.91. The mean (+/- SD) EAT-10 score of the normal cohort was 0.40 +/- 1.01. The mean EAT-10 score was 23.58 +/- 13.18 for patients with esophageal dysphagia, 23.10 +/- 12.22 for those with oropharyngeal dysphagia, 9.19 +/- 12.60 for those with voice disorders, 22.42 +/- 14.06 for those with head and neck cancer, and 11.71 +/- 9.61 for those with reflux. The patients with oropharyngeal and esophageal dysphagia and a history of head and neck cancer had a significantly higher EAT-10 score than did those with reflux or voice disorders (p <0.001). The mean EAT-10 score of the patients with dysphagia improved from 19.87 +/- 10.5 to 5.2 +/- 7.4 after treatment (p <0.001). CONCLUSIONS: The EAT-10 has displayed excellent internal consistency, test-retest reproducibility, and criterion-based validity. The normative data suggest that an EAT-10 score of 3 or higher is abnormal. The instrument may be utilized to document the initial dysphagia severity and monitor the treatment response in persons with a wide array of swallowing disorders.

In-office unsedated transnasal balloon dilation of the esophagus and trachea.

PURPOSE OF REVIEW: Since the advent of ultrathin flexible endoscopes with working channels office-based esophagoscopy and tracheobronchoscopy have been undertaken frequently by otolaryngologists. As a natural extension of these diagnostic procedures, more office-based esophageal and tracheal therapeutic procedures are being undertaken. RECENT FINDINGS: Esophageal and tracheal balloon dilation can be performed in the unsedated patient using a transnasal approach. These transnasal techniques have not been described in the recent literature. Esophageal balloon dilation is a well-accepted technique for gastrointestinal endoscopists, and recent literature has focused on indications (such as cricopharyngeal dysfunction) and the development of removable stents for prevention of restenosis. Pulmonary balloon dilation is likewise well accepted, with recent literature focusing on the timing of intervention and the incidence of tracheobronchial laceration. SUMMARY: Office-based esophageal and tracheal balloon dilations in unsedated patients are newly described techniques made possible with thin-caliber transnasal endoscopes.

In-office transnasal esophagoscope-guided botulinum toxin injection of the lower esophageal sphincter.

PURPOSE OF REVIEW: Thin caliber transnasal esophagoscopes allow for a rapidly expanding array of office-based esophageal procedures, including botulinum toxin injections, in unsedated patients. RECENT FINDINGS: While botulinum toxin has been used in the esophagus and lower esophageal sphincter for many years, there is no current description of performing this procedure in an unsedated patient using transnasal esophagoscopy. Indications include achalasia, hypertensive lower esophageal sphincter, distal esophageal spasm, nutcracker esophagus and obstructing muscular rings. There is a paucity of data in the literature pertaining to spastic esophageal motility disorders and muscular rings. Randomized controlled trials of achalasia treatments suggest that botulinum toxin injections should be reserved for patients who are poor surgical candidates and/or have failed pneumatic dilation. SUMMARY: In-office transnasal esophagoscopy-guided lower esophageal sphincter botulinum toxin injection has not been described in the literature. Indications include esophageal spasm, muscular rings and achalasia, with recent data suggesting that botulinum toxin should not be an initial therapy for most patients with achalasia.

Differentiation of adductor-type spasmodic dysphonia from muscle tension dysphonia by spectral analysis.

OBJECTIVES: To determine the utility of spectral analysis in the differentiation of adductor-type spasmodic dysphonia (AdSD) from muscle tension dysphonia (MTD). STUDY DESIGN: Prospective blinded study. METHODS: Forty-seven samples of AdSD-connected speech spectrograms from 27 subjects and 17 samples of MTD-connected speech spectrograms from 15 subjects were selected from clinical charts and de-identified. These spectrograms were reviewed independently and blindly by two speech language pathologists experienced in spectrography. The speech language pathologists designated the spectrogram as consistent with AdSD and MTD, and these designations were compared with actual clinical diagnoses. RESULTS: The ability to differentiate AdSD from MTD with spectral analysis was 94% for rater #1 and 98% for rater #2. No MTD subjects were incorrectly diagnosed as having SD (100% specificity). CONCLUSIONS: This study suggests that experienced speech language pathologists can distinguish AdSD from MTD with a high degree of sensitivity and specificity based on spectral analysis. Spectral analysis is especially useful in cases where perceptual analysis and clinical evaluation alone are insufficient.

Laryngopharyngeal abnormalities in hospitalized patients with dysphagia.

OBJECTIVES: To determine the prevalence of laryngopharyngeal (LP) abnormalities in hospitalized patients with dysphagia referred for flexible endoscopic evaluation of swallowing (FEES). STUDY DESIGN: Retrospective, blinded review by two otolaryngologists of 100 consecutive FEES studies performed and video-recorded by a speech-language pathologist (SLP). METHODS: Two otolaryngologists reviewed videos of 100 consecutive FEES studies on hospitalized patients with dysphagia for the presence of abnormal LP findings. RESULTS: Sixty-one male and 38 female patients comprised the hospital dysphagia cohort. The mean age was 62. One subject could not be evaluated because of the severity of the retained secretions, leaving 99 subjects in the cohort. Seventy-six percent had been previously intubated, with a mean intubation duration of 13 days. The overall prevalence of abnormal LP findings was 79%. Forty-five percent of the patients presented with two or more findings, which included arytenoid edema (33%), granuloma (31%), vocal fold paresis (24%), mucosal lesions (17%), vocal fold bowing (14%), diffuse edema (11%), airway stenosis (3%), and ulcer (6%). There was a significant difference in LP findings between those individuals who had or had not been intubated. CONCLUSIONS: Hospitalized patients with dysphagia are at high risk for LP abnormalities, particularly if they have been intubated, and may benefit from either 1) an initial joint examination by the SLP and otolaryngologist or 2) an otolaryngologist's review of the recorded examination conducted by the SLP. Such otolaryngology involvement could identify airway stenosis patients at an earlier stage, initiate granuloma treatment sooner, enable earlier biopsy of unexpected lesions, and allow follow-up of mucosal and neuromuscular findings that do not respond to medical management.

Reliability of the pharyngeal squeeze maneuver.

OBJECTIVES: Fiberoptic endoscopic evaluation of swallowing with sensory testing has been used to assess the integrity of laryngopharyngeal sensory and motor components. The pharyngeal squeeze is a maneuver used during fiberoptic endoscopic evaluation of swallowing with sensory testing to assess pharyngeal motor function. Although the pharyngeal squeeze manuever has been used in numerous scientific publications, its reliability has not been critically evaluated. Therefore, we sought to evaluate the reliability of the pharyngeal squeeze maneuver. METHODS: Forty individuals who were undergoing fiberoptic laryngoscopy for various reasons were instructed to perform the pharyngeal squeeze maneuver. Three different clinicians reviewed the videotape on 4 separate occasions. The clinicians were first asked to rate each side of the pharynx as normal, diminished, or absent. They were then instructed to simply rate the maneuver as normal or abnormal. The interobserver and intraobserver reliability of the pharyngeal squeeze maneuver were assessed with the kappa coefficient. RESULTS: The mean age of the cohort was 58 years. Fifty-eight percent (23 of 40) were male. When the clinicians were instructed to rate each side of the pharynx as normal, diminished, or absent, the interobserver and intraobserver reliabilities were poor (63% to 68% agreement; kappa = 0.18 to 0.67). When the clinicians were asked to rate the pharyngeal squeeze maneuver as normal or abnormal, both interobserver and intraobserver reliabilities were excellent (85% to 98% agreement; kappa = 0.75 to 0.95). CONCLUSIONS: The pharyngeal squeeze maneuver displayed poor reliability when motor function was classified into unilateral or bilateral normal, diminished, and absent categories. The pharyngeal squeeze maneuver was very reliable when simply graded as normal or abnormal. Clinicians could not reliably distinguish between diminished and absent pharyngeal motor functions.